Cesarean Voices-A
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| contributors | networkingThe Emotional Ramifications
of Being born in a Caesarean Delivery by
Amy Lauren Shapira

(Written for a graduate level psychology class, this article
gives a good brief summary of what is currently know about the
experience of people born cesarean. Amy Shapira is currently (2008)
working on a Master's degree at Santa Barbara Graduate Institute.)

Introduction

Caesarean deliveries are the number one major surgery in the
United States, where the rate has gone from 2 to 3 percent in
the 1970s (Verny, & Weintraub, 2002) to 31.1 percent in 2006
(Yabroff, 2008), exceeding the recommendation by the World Health
Organization (WHO) that caesarean deliveries should make up less
than 15% of all births and less than 9.5% in wealthy, westernized
nations. Around the world, rates of caesarean sections are soaring
as well. In 2004, caesarean delivery rates were as high as 90%
in some private clinics in Brazil (Song, 2004).

Interest in the experience of childbirth has increased enormously
in the United States since the 1970s. Much emphasis has been placed
on having an optimal childbirth experience and on early parent-infant
bonding (Affonso, 1981). Still, the process of birth has never
been so medicalized as well as regulated by state legislation,
insurance companies, and other bureaucratic systems (Noble, 1993).

The emphasis in the obstetrical health team has long been on
the physiological outcome of caesarean childbirth both for the
mother and the newborn (Affonso, 1981). Groups such as the VBAC
(Vaginal Birth After Caesarean) movement and C - sect have, for
several years, been addressing the mother's perspective and the
question of the politics of too many caesareans (English, 1994).
Though caesarean deliveries save the lives of mother and child,
little attention and respect have been given to the baby and the
baby's emotional well-being by the obstetric health team (Oliver,
2000).

In this paper I will review the prenatal and perinatal research
literature on the emotional ramifications of being born in a caesarean
delivery. The first section will describe the perinatal experience
of the caesarean born, the second will discuss how this experience
has been shown to affect a caesarean born personality and relationships
later on in life and the last part will talk about how modifications
in the "routine" can humanize caesarean delivery for
the newborn, the mother and the father to meet both the goals
of caesarean delivery and family-centered childbirth.

Literature Review

In this section I will review the literature on the emotional
ramifications of being born in a caesarean delivery. There are
two kinds of caesarean deliveries: those done before labor starts
and those done, often in emergency conditions, after some labor.
Since the usual medical terms, elective caesarean and non-elective
caesarean, focus on the doctor's and the mother's experience,
and this paper focuses on the child's experience, I will use Jane
English's (1985) definitions of the two kinds of caesarean born:
"non labor caesarean" defines the child who is born
in an elective caesarean and "labor caesarean" defines
the child who is born in a non-elective caesarean.

Evidence of birth memory, especially associated with trauma,
has been reported frequently in the last seventy years (Noble,
1993) and the importance of the birth experience in formation
of self image and world view has been documented in works by Feher
and Grof (English, 1994). Freud was the first to propose that
birth can be remembered and that it can influence personality
(Feher, 1981; Verny & Weintraub, 2002). Rank believed all
neurotic anxieties were repetition of the physiological phenomenon
of birth (Feher, 1981). Leslie Feher (1981) in her book The
Psychology of Birth: Roots of Human Personality,states
that "all patterns in life are metamorphic re-enactments
of birth" (p. 68). Feher, who is a psychotherapist, claims
that studies of case histories, work with patients and broader
surveys have all led her to believe that certain personality structures
relate to specific birth experiences. Feher admits that much of
this material can be considered hypothetical and that there is
a need for large controlled trials to scientifically validate
her observations and assumptions.

Verny and Weintraub (2002) in their book Tomorrow's Baby,
stress that although a cause-and-effect relationship between mode
of birth and personality is not suggested, there is a consensus
among the findings of clinicians working in the field of prenatal
and perinatal psychology, that prenatal and perinatal factors
create a predisposition that may be exacerbated and adversely
affect one's personality. As they discuss the influence our birth
can have on our life they eloquently state, that "birth is
a transformative psychological event, a psychic pacemaker that
unconsciously motivates our subsequent life. How we enter this
world plays a crucial role in how we live in it" (p. 70).

In light of these works it is essential to examine what it
is like for the child to be born via a caesarean. How do the caesarean
born individuals differ in their basic personality, life attitudes
and strategies, and interpersonal relationships from vaginally
born individuals? Do caesarean-born individuals have distinct
personality traits that are associated with the way they entered
the world?

Jane English (1985) was one of the first to address these issues
in her book Different Doorway: Adventures of a Cesarean
Born.In her book, English, an artist, translator,
and photographer who has a PhD in sub-atomic particle physics,
describes her ten year journey of self discovery and exploring
the personal, social and spiritual implications of having herself
been born non-labor caesarean. In her journey, English followed
practices such as mindful meditation, rebirthing, Gestalt therapy
and more. Her book consists of excerpts from her journal offering
dreams, imagery, and insights into being caesarean born as well
as informative interviews she had conducted with other caesarean
born individuals.

Prior to this book, most of the literature on caesarean birth
viewed it as being abnormal, pathological, or unfortunate (English,
1994). English (1985) indicates that her intention in her book
was to show that a caesarean birth is neither more nor less intense
than vaginal birth but that it is simply different. In Different
Doorway, English has sketched the first map of caesarean-born
experience but stresses the fact that the material presented is
anecdotal rather than scientific and that the map is not intended
to categorize all caesarean birthed people but to offer a conceptual
framework.

The Perinatal Experience of the Caesarean
Born

English (1994), in her article Being Born Caesarean: Physical,
Psychosocial and Metaphysical Aspects, presents a map describing
the perinatal experience of the non-labor caesarean outlining
each step of the caesarean delivery and how these could be subjectively
experienced by the baby being delivered. She then explains how
this experience of being delivered by caesarean differs from the
experience of being born vaginally which could account for distinct
habits, expectations and personality traits in the caesarean born.

Before any procedure is begun, English (1994) describes the
subjective experience of the unborn child as "primal oceanic
union" with the mother. This union is disturbed by general
anesthesia used in surgery which could be experienced by the unborn
child as poisoning and being attacked (when regional anesthesia
is used there may be less sense of aloneness as the mother's consciousness
is still present). The next procedure is the incision made in
the mother's abdomen and uterus. This, English states, could be
shocking to baby who is still unified physically and psychically
with the mother.

The obstetrician then abruptly pulls the baby, who is still
very much in a state of cosmic union, out of the womb (English,
1994). Noble (1993) states, that the non-labor caesarean is physiologically
not ready for delivery at this point, since his systems, have
not gone through the hormonal changes which prepare them for birth.
In addition, the baby may experience lack of oxygen as he is lifted
up above his blood supply (Noble, 1993; English, 1994). Delivery
of the baby is followed by cutting the umbilical cord (English,
1994).

English (1994) believes it is necessary to include the encounter
with the obstetrician as part of the birth. The encounter, she
states, consists of a struggle with the obstetrician who suctions
the baby's airways (because the amniotic fluid is not squeezed
out of the lungs, as in vaginal delivery) and then forcefully
stimulates the baby's breathing. But the encounter, according
to English also includes an experience of bonding with the obstetrician
which is the first to touch the baby and make eye contact with
him. However, this new bond is soon broken as the baby is taken
away to the nursery (English, 1994) and could be separated from
the mother for as long as 24 hours (Noble, 1993).

It should be noted, that this experience may be different for
caesareans being delivered more recently as some hospitals' caesarean
protocols may be advanced. For example, some hospitals may use
regional anesthesia enabling the mother to be awake during the
delivery. Some may permit the father to be present in the operating
room and so forth. The experience is also partially different
for the labor caesarean, who experiences some labor before being
delivered by caesarean section.Caesarean Personality and Relationships

Personality traits of the caesarean born have been described
and addressed by numerous authors (Feher, 1981; Ray & Mandel,
1987; Verny & Weintraub, 2002, Noble, 1993). These authors
link caesarean born personality traits to the perinatal experience
of the individual born in caesarean delivery. Feher (1981) states
that the caesarean born encounter difficulty dealing with complications
leading to goals since they never experienced the conflict of
birth as the vaginally born do. According to Feher, the caesarean
adult expects things to be handed to him and needs the help of
others to accomplish anything. In case of failure, the caesarean
will blame others for not helping enough.

Feher (1981) says the caesarean born have difficulty understanding
processes in general, having missed experiencing the transitional
phases during contractions. This makes frustrations and responsibilities
difficult to deal with. Feher adds that caesareans in general
have problems in learning.

Having missed out on the initial massage the walls of the birth
canal provide at birth, the caesarean born craves physical affection
(Ray & Mandel, 1987; Verny & Weintraub, 2002). If one
doesn't get it as a child, they may still need what seems like
an excess of caressing as adults (Ray & Mandel, 1987). Not
experiencing the high pressure squeezing of contractions and the
journey down the birth canal, non labor caesareans have a different
learning experience in terms of personal space. They may not have
a strong sense of boundaries and limits and they tend to continuously
test limits and boundaries. Many caesarean-born are "put
in place" over and over, and are told not to be intrusive
by people who expect them to have an inborn sense of limits (English,
1994).

Verny and Weintraub (2002) state the caesarean born tend to
get into difficult situations and hope to be rescued. Caesareans
tend not to know how to push through barriers, as their birth
script is often looking for a savior because that is what happened
during birth (Noble, 1993). Because the baby is separated from
the mother's womb very abruptly in a caesarean birth, a procedure
which sometimes involves an emergency operation accompanied by
much fear and tension, caesareans are prone to be hypersensitive
about issues of separation and abandonment (English, 1985; Noble,
1993; Verny & Weintraub, 2002).

When a birth doesn't happen naturally, the baby doesn't feel
responsible for it. This may set up a need to find someone who
will constantly "give birth" to them (Noble, 1993).
English (1994) points out that caesarean birth is not limited
in time to the removal of the baby from the mother, but continues
for years. English (1985) writes, "'Birth' on the physical
level for a caesarean is much quicker than for the vaginally born.
But paradoxically, caesarean birth also can be seen as taking
much longer. Many physiological, psychological and maybe even
spiritual processes that occur in labor and delivery for the vaginally
born happen for caesareans, if they happen at all, in their encounters
with the world and with people" (p. 59).

In their book Birth & Relationships (1987) Sondra
Ray and Bob Mandel discuss how birth influences the dynamics of
relationships. Relating to caesarean relationships they write,

A caesarean's relationships tend to be characterized by conflicts
of will, changes of heart and mind, and constant disruptions...
usually they are looking for someone outside the relationship
to tell them which way to go in life, then resenting it and doing
the opposite. If one partner is caesarean and the other is not,
the latter can be set to be the obstetrician - which happens
in many relationships (pp. 83-84)

English (1985, 1994) talks about caesarean born relationships
as being colorful, abrupt, and intense, characteristics which
are related to the caesarean's different sense of time and space
learned during delivery. She describes them as having an "all
or nothing", arrow like quality rather than a wave like quality
of contraction and expansion that would be learned in vaginal
birth. Like Feher (1981), she addresses the little sense of process
in the caesarean born, which is manifested in relationships in
a tendency to expect that a relationship either exists and doesn't
need to be nourished, or doesn't exist and is impossible.

English (1985) points out some positive aspects of being born
caesarean,

I think there is also a sense of pioneering and leadership
among caesareans ... A certain strength comes from living outside
the mainstream ... Caesarean birth is an ideal structure for
allowing something new to come through into the world. It sets
aside some deep patterns that have been common to all human culture.
We begin to realize that we don't have to do some things the
way people have been doing them for thousands of years"
(p. 130)

English (1994) believes the caesarean born have easy access
to transpersonal awareness. Feher (1981) too, appreciates the
positive qualities of caesarean personality stating that a caesarean-born
can be enthusiastic, spontaneous, and artistic.

Discussion

Caesarean rates are soaring in the United States as well as
around the world. There has been much concern about the medical
complications related to the caesarean procedure both in the mother
and the newborn. The emotional impact of undergoing a caesarean
section on the woman and the impact on maternal - infant bonding
have been studied and addressed as well (Affonso, 1981).

Evidence from the pre and perinatal literature suggests that
we are conscious sentient beings prior to physical life (McCarty,
2004). Unborn children remember the experience of gestation and
birth and these memories become the foundation for feelings and
behaviors throughout life (Verny & Weintraub, 2002). Jane
English's research, although subjective and anecdotal, represents
a pioneering venture as she has been the first to sketch a map
of caesarean-born experience and personality patterns. Further
studies are needed to scientifically validate the suggested correlations
between behavior and personality patterns and birth experience.

In an era when one in three babies is born by caesarean delivery
it is imperative that society consider the emotional implications
of being born in a caesarean delivery and strive to create changes
in hospitals' caesarean birth protocols to humanize the experience
for the child, the mother and the father. Dr. Robert Oliver (2000),
an obstetrician, in his article The Ideal Caesarean Birth,
claims that the new models of optimizing the childbirth experience
have eluded caesarean delivery, where little respect is given
to the baby and the baby's wellbeing.

Oliver (2000) believes it is crucial the obstetric team understand
the metaphysical and transformative aspects of labor and spiritually
welcome the baby through prayer and meditation. He suggests numerous
ways in which caesarean birth could be humanized even in an emergency
circumstance when the obstetric team has less than ten minutes
to deliver the baby.

In the case of an elective caesarean, when the mother and baby
are healthy, Oliver (2000) suggests to allow labor to start before
performing the surgery which can ensure fewer complications for
mother and baby. By using regional anesthesia the mother can be
conscious throughout the delivery and breastfeed and bond with
her baby after he is born. Oliver recommends a transverse incision
so that the mother has the opportunity in the future for a vaginal
birth and that the amniotic sac not be ruptured until after the
baby's presenting part is elevated gently. The nose and throat
can be gently aspirated if needed and the rest of the body is
then delivered but not by the pulling of the head.

The baby could be gently compressed by the hands of the obstetrician
to simulate vaginal passage, and can be covered with more warm,
wet hands or towel while waiting for fetal circulation to stop.
The cord should be clamped only after it stops pulsating and the
baby is then given to the mother and the father while the pediatrician
judges the condition of the baby and decides whether gentle stimulation
of breathing is needed. The obstetrician completes the delivery
of the placenta, awaiting its delivery instead of jerking it out,
and closes the uterus and abdomen Oliver (2000).

Oliver (2000) believes that this ideal is possible but that
there will have to be a tremendous awakening of the medical community
to the need for this caesarean birth. Apparently, Dr. Oliver's
vision of humanizing caesarean delivery is shared as well as practiced
by other obstetricians. According to an article published in The
Guardian (Moorhead, 2005), Professor Nick Fisk, an obstetrician
at Queen Charlotte's and Chelsea hospital in west London, practices
what he calls "a 'natural' caesarean section" which
is performed quite similarly to Dr. Oliver's recommendations.

Professor Fisk (Moorhead, 2005) states: "... while couples
having normal deliveries have been given more and more opportunities
to be fully involved in childbirth, very little has been done
to see how we could make the experience more meaningful for those
having caesareans" (Morrhead, 2005, para 5). He also states
that caesareans are done a certain way because that is how they
have always been done, when in fact they could be done differently
- and in a way that parents feel better about. Jenny Smith, a
midwife who works closely with Fisk, describes the benefits of
performing a "natural caesarean": "the parents
feel more involved, which gives them a better start to family
life, breastfeeding is easier to establish, and one can see how
much calmer the baby is".

Dr. Chris Gunnell, an Australian obstetrician, has just started
performing "assisted caesarean" deliveries, a procedure
that allows the mother to be the first to hold her child, with
her hands guided into the womb by medical staff (Dowling, 2007).
"Assisted caesarean" is unlikely to become mainstream
procedure as Dr. Gunnell states, "Speaking to a lot of women
and talking about this, many of them are actually grossed out
about the idea; they don't like the concept of helping" (Dowling,
2007, para 14). Dr. Gunnell adds that there are still a lot of
things to work on before "assisted caesarean" becomes
standard, if at all. For example, the risk of infection needs
to be addressed.

It is evident that, not only does the medical community need
to become aware of the need to humanize caesarean birth, but future
parents need to be educated about this subject as well.